This transcript has been edited for clarity.
Eric J. Topol, MD: Hello. This is Eric Topol from Medscape, with my colleague and co-host Abraham Verghese for a new edition of the Medicine and the Machine podcast. We are privileged to have Dr Jeremy Farrar from the United Kingdom, a physician-scientist who has lived and worked all over the world, Since 2013, he has headed the Wellcome Trust.
Jeremy Farrar: It's a great honor to join you.
Topol: We have much to talk about. The pandemic has been perhaps far worse and longer than many had envisioned when it got its legs in early 2020. Where do you think we're headed now?
Farrar: That's difficult. I was more certain of things in 2020 than I am in 2021. We are at a difficult juncture. We have to change our way of thinking about the end of the pandemic, because we're entering a new phase of endemicity with different impacts in different part of the world, largely defined by inequitable access to the tools that we need and the interventions. Seeing the end of the pandemic is premature. We need a different mindset and that will come with a different way of thinking, and I hope would include a different way of investing in the critical interventions that we need.
Topol: You have just published a new book, Spike: The Virus vs. the People – The Inside Story. Abraham had the chance to read it in preparation for our discussion, so I'll turn it over to him.
Abraham Verghese, MD: Jeremy, what a pleasure to have you here. I was up late last night reading Spike. It was a delight. I can't think of another book telling the story from the frontline of this epidemic as it first emerged. You were in a unique position with your prior experience with SARS, knowing all these people, and with your prior experience with SARS and all the outbreaks in China and Hong Kong. You have a remarkable perspective on the story. For the benefit of our listeners, could you talk us through those early days?
Farrar: It's been an incredible 18 months. We have long been predicting a pandemic, but none of us could have predicted the scale of the disruption that has happened. Those early days were very frightening. I frame the pandemic around critical elements that existed before the pandemic hit: the neglect of public health, the geopolitics of the time, and the lack of appreciation of the warning signals over the past 20 years, from Nipah to SARS, bird flu to H1N1, Zika, MERS, and Ebola. These were all giving us warnings which, frankly, we didn't take heed of. Then in the first months of 2020, the release of information was delayed. I have no doubt there were some delays in China. What caused those delays is controversial. I think it's more complicated to know how the pandemic started than you might think it is. Nevertheless, there were some delays and those were very important.
On the 24th of January, we knew that this was a novel human infection spread by the respiratory tract with asymptomatic transmission. And it was a novel coronavirus to which we had no drugs, no diagnostic tests, no vaccines, and questionable immunity. From that moment onwards, the path of the next 18 months was set in many ways. Many countries around the world, I'm afraid, did not take heed of that warning on the 24th of January and prepare as they should have.
Verghese: I was really struck by your listing of the dramatis personae at the end of the book and the fact that most of those folks are people who you know well enough to grab your phone and text. I was also struck by the ethical dilemma posed by being aware that this information needed to be released and shouldn't be embargoed by a journal. That makes for such compelling reading. You felt you needed to get a burner phone because of the sense of crisis and threat.
Farrar: I didn't even know what a burner phone was in January 2020. I subsequently learned what it was, but I've never been able to articulate what I was frightened of, except that I did find it very frightening. I'm a doctor. I'm a scientist. I'm not a spy. I haven't worked in high-level politics or for the secret services. Yet here you were. And we've got to remember, this was at a time of the previous administration in the United States under President Trump and the tensions with China — not just America, but other parts of the world as well. You felt in the middle of that crisis.
There were accusations and blame over who knew what, when and where did the virus come from — controversies that continue to haunt us today in many ways. It was a scary time and a time of chaos. I've been through previous epidemics. It's always a very frightening time — frightening for your security, your health, and your family's health. And you're not in control of events.
Topol: Let's get into a topic you've already touched on. It's becoming a bigger issue almost every day now — the global vaccine equity goal, which is so vital. You've been a leader on the importance of that. And now we have the booster story. The United Kingdom is going forward with boosters over age 50. And as you know, there's an article in The Lancet this week from the FDA scientists and others saying there are no good data yet for boosters. Data are coming out this week from Israel about boosters for those over 60. More than a million people got a third shot and they saw restoration of the vaccine's effectiveness against hospitalization and severe illness. So we have this dilemma here where countries turn inward rather than outward and helping get the planet in order. What are we going to do, Jeremy?
Farrar: In September 2021, this is the key issue because the vaccines have been remarkably good. A year ago, we could not honestly have dreamed of having a portfolio of vaccines from many different manufacturers which were so effective, so safe, and developed so quickly. We're in a remarkably strong position and the vaccines have been very good, particularly in preventing illness, hospitalization, and deaths. But I don't believe they give herd immunity, population immunity, in the same way we think about measles. They give an enormous benefit to those who are vaccinated, but if you're not vaccinated, you're getting less benefit from the vaccinated population around you.
We are now in a world essentially defined by access to the vaccines in North America, the United States, and Europe, where vaccine uptake is high, but it's not as high as it could be. In the UK, for instance, close to 90% of adults have now two doses, and that has kept a lid on hospitalizations and deaths. But there seems to be some waning. The longevity, the length of time the vaccines are protecting people, is not years. We run the risk of having to vaccinate on a very regular basis and yet not having the global manufacturing and distribution capacity to provide these essential interventions for the rest of the world, let alone health systems that can deliver them.
This is a defining moment for the 21st century: How can we bridge this domestic pressure on governments to supply their own citizens, which is understandable, with the moral, ethical, and indeed public health and scientific imperative of providing these vaccines globally — not only to prevent deaths but also to prevent variants developing in the future? If I'm being optimistic, we may be in the worst possible moment now where supply is far below demand. I would hope that toward the end of the year and into next year, the supply will increase and we will be able to provide those doses globally. We must do so as quickly as possible.
Topol: How do you reconcile the WHO calling for a moratorium when countries like the UK, the US, and others are going ahead with boosters against the will of WHO?
Farrar: This is realpolitik. If you are an elected or unelected leader of a country or a politician, your prime responsibility is to your citizens. We all understand that. And there's a trade-off here between providing for your own citizens vs the moral and ethical push to provide these lifesaving vaccines to the citizens of other countries. At the moment, I don't believe any country is dealing with this. Personally, I would rather we were making the vaccines available globally than offering booster doses in countries that have already reached 90% vaccine coverage in their adult populations. I lean toward the arguments from the Lancet paper published this week from the WHO, calling for greater vaccine distribution globally before we offer boosting doses to our own citizens, with some caveats: For healthcare workers, the elderly, and people with other comorbidities who are at greater risk, boosting doses are justified in all countries. But I wouldn't be offering boosting doses to the whole adult population, not when we still have many countries with 1%-2% vaccine uptake.
Topol: All three of us are 60 or older. Are you including us in the elderly category?
Farrar: I only turned 60 last week. I know the data you are talking about from Israel, but I would put it older. The risk to somebody of my age, having had two doses of the vaccine, and not knowingly infected, I feel reasonably well protected against getting sick, going to hospital, or dying, enough that I would rather offer any booster dose that I am offered be given to another country.
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Verghese: Toward the end of the book, you say, "In my view, the pandemic has been a catastrophic failure of global diplomacy, at just the time we need cooperation." Do you think that anything has changed? In other words, with the next virus coming down the pike, are we in a better position to react than we were in December of 2019?
Farrar: The scientific advances of the past 18 months have been simply staggering; from a genome to having 10, 11, 15 billion doses of a vaccine within 8 months is absolutely extraordinary, from the research community, the scientific community, industry, and everyone who has been involved. An absolutely staggering achievement. We could do it faster in the future. We could get to this in 30 days, and we could be vaccinating the world within 100 days. That should be our aim.
But are we, as a world, better off in terms of preparing for future stresses? On that, I'm much more pessimistic. We have some geopolitical tensions at the moment which are making the world very unsafe, and the undermining of the WHO over many years — but particularly in the past 5 years — has led to a weakened WHO.
This is much broader than pandemics. If you look at all the great challenges of the 21st century, we could argue about what they are. But climate change, pandemics, drug-resistant infections, energy access, and water access are some of the great challenges of our time. None of them are national. In reality, they are all transnational. They all have science somewhere at the heart of them trying to make a difference, to make an impact. They all have the critical need for societies and communities to be engaged with that science and understand that science. They require geopolitical cooperation and collaboration at a time when we are very polarized in the United States, in the United Kingdom, in Europe, and between east, west, north, and south. I don't think that bodes well for dealing with the challenges we face in the 21st century.
Verghese: There's a lot of talk in today's paper about how the UK is thinking about and planning for the upcoming winter and what they might do to avoid a lockdown. What do you think is going to happen this winter? How do you think the government will react if there is another storm surge? It seems like there is no appetite for a lockdown, and yet nothing less might be effective in preventing the spread.
Farrar: The seasonality of this infection has perhaps been overstated. Nevertheless, going into the fall and the winter, when people will be congregating more inside and in worse-ventilated environments, our schools are going back, colleges are going back, and workplaces are going back... This is going to put pressure on every area and particularly those people who are not vaccinated or in whom the vaccine immunity is waning. We will see an increase in transmission in North America and Europe over the coming weeks and months.
I would like to think that we would take some measures earlier on to prevent the need for lockdowns, but we shouldn't underestimate the impact that vaccines are having. September 2021 is a totally different environment to September 2020. If you're in a country, a region, a state, or a city that has had good vaccine uptake; if you're in a country with no access to the vaccine; if you're in a state in the United States or city in the UK where vaccine uptake remains very low, the health system and you as an individual are very vulnerable, I'm afraid, going into this winter. So the answer is to take the vaccines if you possibly can, and take public health measures earlier rather than later — wearing masks, handwashing, avoiding crowded indoor spaces — in order to keep as much of society open as we can through the winter of 2021-2022.
Topol: I'd like to get your views beyond the Delta strain. This version of the virus took a detour in antigenic drift from Alpha, Beta, Gamma and has become not just a problem for transmissibility, but it also seems that part of the story is the immune evasiveness property. Will we see a strain worse than Delta? Also, why aren't we gearing up for a universal coronavirus vaccine that is at least a subfamily that would take on all variants of SARS-CoV-2? What are your expectations about further evolution of the virus? And why are we aren't anticipating that with better vaccines?
Farrar: The scientific community has to work on the basis that there will be further variants. We have to make that assumption. That's why we need to get away from this idea that we're close to the end of the pandemic; because once you get to that mindset, you stop thinking, you start planning for the future. You stop investing in the critical infrastructure that's needed. We need to see this as the marathon it is. We're not going to come out of this pandemic in the sense that suddenly we don't have to deal with it. We are now dealing with an endemic human infection that will be with us forever, or at least for many years.
We also have to work on the assumption that with the very inequitable distribution of immunity we have around the world (some are immune, some are not, and some might be), that is the perfect environment for new variants to arise. If you had to design a global experiment to encourage new variants, you would do what we're doing in the world today. You take 7 billion people, make some of them totally immune, some nonimmune, and some in the middle with partial immunity from the waning over time of imperfect vaccines. That's where we are.
We have to assume that we will see further variants coming, and those variants will now be trying through evolution to escape immunity. So we should be thinking of second- and third-generation vaccines and thinking of them as much broader than Delta or Beta or Gamma or even this coronavirus. We should be thinking about how we can create transmission-blocking vaccines, not just vaccines that prevent illness, hospitalizations, and deaths. Because ultimately what we need is a long-acting vaccine that we can give to everybody, which will give them protection against the betacoronavirus families, both in terms of blocking transmission as well as blocking illness. And we need to invest in that yesterday, today, and tomorrow to get to that state as soon as we can.
Topol: You're bringing up such a critical point about the lack of a priority given to a nasal or oral vaccine to deal with mucosal immunity that would complement the shots. We have this narrow vision about shots. There are other things that we could press on with, including drugs beyond just monoclonal antibodies that could be used for prevention. Why do we have such a vaccine-centric strategy? It seems as though there are enough resources in countries like the UK, the US, and others that we could plan more broadly at this point.
Farrar: We have to be. There is no single magic bullet to work our way through this. COVID vaccines are clearly critically important, but so is diagnostic testing, sequencing variants, oxygen, personal protective equipment, behavioral change, social sciences, and critical treatments. Broad transmission-blocking second-generation vaccines are critical.
With respect to treatments, our development of drugs for acute viral infections has not been good. This is an opportunity to change that, just as we've changed through the mRNAs and the monoclonal antibodies; we can use this as a catalyst that will produce new treatments for COVID, but also through advances in science, produce new treatments for influenza and other acute viral infections that are going to be so important in the 21st century. It's an opportunity to grasp, to really transform, the way science looks at this. But we need to stop thinking that the pandemic is coming to an end — that we've dealt with it and we've been through the worst. We need to counter that mindset and think longer term about how we're going to deal with this over the whole of this decade, if not longer.
Verghese: You are in the unique position of leading the Wellcome Foundation, which has done so much for tropical diseases all over the world. What strategies are you using now in terms of COVID? What are your efforts in that direction?
Farrar: I'm pleased to say a lot of it aligns with what Eric was just asking about, and that is to step back a little and say we've made massive, fantastic advances in the RNA vaccines, the adeno prime boost, and other technologies. But what we now need to invest in is discovery science, basic science — understanding virology and where treatments and new vaccines are going to come from so that we are not going to suddenly hit a brick wall in a year or two when we need new vaccines and treatments. We need to invest in that longer-term perspective for where we're going to end up. We are going to need new treatments, broader-spectrum vaccines, and transmission-blocking vaccines. We need to invest in that science today so that in 2 years or 5 years, we've already done the basic science needed to achieve those treatments and vaccines. That's probably the biggest contribution we can make at the moment, as well as making the case for equitable access to our existing tools.
Topol: It strikes me, Jeremy, that you've been preparing for this pandemic your entire career with your background. You headed up the Oxford Research Center in Vietnam and your work in virology, infectious disease, and immunology. I don't know anyone who has a better background to be a global leader not just in thinking, but in taking action during the pandemic. Have you reflected on the fact that you would be in a very important position to help advise the United Kingdom and people around the world?
Farrar: There are lot of people, including yourself, with similar sorts of backgrounds. Originally I trained as a neurologist. I had no interest in infectious diseases until the mid-1990s when the idea of becoming a clinical neurologist was not quite as attractive as I thought it when I went into it.
That says something very important for our careers. I am a great believer in people being able to swap careers and bring skills that they have from cardiology or from immunology or infectious diseases. In my case, it was neurology into infectious diseases. There's great synergy at the interface of two specialties. I'm concerned that we define young clinicians and scientists too early. We want them to be very deep, but this is a time when we actually need polymaths and breadth and people who appreciate the interfaces and have the humility to understand that a neurologist and a cardiologist or an immunologist and an endocrinologist can work together. That is the future. One of my concerns for the way we train people now is whether we really allow and encourage those interfaces to happen, including outside medicine, into the social sciences, behavioral sciences, psychology, or ethics. I worry that we're training people too narrowly and too early and not allowing those interfaces, which I think are the exciting areas of science to develop.
Topol: There's a lot of wisdom there. I have a question about tough love. You advise the UK extensively, and I've been on at least one call about the G7 with you. And you wrote a book that really takes on the UK government. Has that put you in a tough position at times where you're criticizing the leadership, but also advising them at the same time?
Farrar: Yes, of course, but t's very important to try to avoid being personal. It's not about personalities and people; it's collective. I'm not part of government. I'm independent of government. If you are independent of government, you have a responsibility to say what you think. I appreciate that the people within the government do have to take the cabinet decisions and remain truthful to the government's approach. For those of us who are outside government, that comes with the responsibility to be positive and constructive, but also critical when needed. That's where the added value of being independent comes. It's not personal, but it has been tough at times, as I'm sure you've found in the United States as well.
Verghese: I want to bring you back to a question about the book. Were you keeping a diary? Because the opening pages of the book read like a fast-paced thriller. Yet there are great details there. I'd love to know the mechanics of how you reconstructed those interesting first 6 weeks or so.
Farrar: I had never kept a diary in my whole life, but from about the third or fourth of January, I felt it was important, given what I thought was coming, to keep colleagues at Wellcome and outside Wellcome (for example, the UK government) updated on my thinking about where things were going. A lot of different conversations were going on, you can imagine. I felt it was important, so once every 2-3 weeks I documented what I thought at the time without thinking that it would ever come to any utility other than keeping people apprised at the time. I just wanted my colleagues at Wellcome to know what was happening. I wrote every 2-4 weeks over the past 18 months. I haven't gone back and changed any of it.
The original documents have been donated to the Wellcome museum so that if anybody in the future is interested in going back and reading them, it will be a contemporary record of at least one person's perspective — unadulterated, unedited, bad grammar, bad English, and the rest of it. I believe historians and political scientists will still be thinking about this 100 years from now, as we thought about 1918 and learned lessons from St. Louis in the United States about what they did and didn't do. We're living through a remarkable period in history.
Verghese: Indeed. We've already getting close to eclipsing the deaths from the 1918 pandemic. This is an event that will never be forgotten. Your book is a wonderful record of that time, a very unique perspective.
Farrar: What you just said is so important, to just stop and think about. In the United States, you will soon pass the number of deaths you had in 1918. My guess is that we've already passed that state globally. Given the paucity of data around the world, I suspect we're getting toward 20 million deaths already. And that is in the context of modern medicine, modern public health, a rich world not coming out of World War I. In 2021, with all of the medical care we have now — fluid replacement, oxygen, and intensive care units — that's a staggering thought. And we're only 18 months into it.
Topol: The optimists would say that it's not corrected for population of the planet, of course. But we all know that it's devastating. Not to minimize the loss of life, but the chronicity for people who have been hit with COVID, which is still underrecognized and not adequately characterized, tends to get lost when we look at just the deaths and hospitalizations.
It was a privilege to have you join us today, Jeremy, but also to learn from you and get your guidance throughout the pandemic. As you say, it's not just an independent voice but one with a lot of background, a lot of wisdom, and a lot of thoughtfulness. Thank you for all you're doing. We're going to continue to follow you very closely for a perspective outside of the US, because the US tends to get too excited about all their fine management of the pandemic when it's perhaps best seen as just the opposite. So it's good to get your views on that. Thanks so much for all you're doing. And obviously we have a long way to go to reach some kind of exit ramp and get out of this thing.
Farrar: Thank you very much. It's an honor to join you, and thank you both for your leadership as well. The United States at various times in its history has flirted with looking inward. We understand that. But the world is better with the United States' leadership, and being part of the global community and its leadership in global health has been absolutely critical. So it's been a difficult few years, but we're very, very pleased you're back.
Topol: I hope so. I hope we stay that way. Our Medscape audience will be interested in your model of the physician scientist and how they can influence the future. Thank you.
This podcast is intended for US healthcare professionals only.
Eric J. Topol, MD, is one of the top 10 most cited researchers in medicine and frequently writes about technology in healthcare, including in his latest book, Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again.
Abraham Verghese, MD, is a critically acclaimed best-selling author and a physician with an international reputation for his focus on healing in an era when technology often overwhelms the human side of medicine.
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